Earlier this year, a group of health policy researchers uncovered a potential unintended consequence of disclosing drugmaker payments to doctors.
Increased transparency diminished Americans' trust in the physician profession, regardless of whether or not their own doctor actually took industry money, survey results showed.
University of Pennsylvania's Genevieve Kanter was the lead author for the paper, published earlier this year in JAMA Open, along with researchers from Harvard and Stanford. The group compared trust scores in states where industry payments were newly disclosed via the federal Open Payments database.
BioPharma Dive talked to Kanter about her research, the broader question of pharmaceutical company engagement with doctors and transparency's limits.
This interview has been condensed and edited for clarity.
BIOPHARMA DIVE: How common is the industry practice of paying physicians?
KANTER: We can think of two different statistics. One is the percentage of doctors who receive industry payments. Depending on the specialty, that can range from 40% to 80%. A substantial fraction of physicians do receive some kind of payment. It could be small, but some kind of financial compensation from industry in any given year.
We looked at a slightly different measure, because we were interested in impact potentially on patients. So we did a study taking a nationally representative sample of Americans who told us who their doctors were. Then we went and linked the doctors to these payments they received. What we found was about two-thirds of Americans saw doctors who had received payments in the previous year.
What did your research find?
KANTER:We were able to take a nationally representative sample of Americans and follow them. We interviewed them before Open Payments, this national release of payment information, and after.
There were a couple of things that we took from the study that we did. One was we wanted to get just the scope of the interaction that patients had with doctors who did interact with industry. We got a reasonable estimate of that.
The second was we were interested in whether patients actually became more knowledgeable or used this information, that was the second paper. And what we found was, compared to before this Open Payments industry payments information was released, there was actually very little change in either patients' knowledge about this issue or in whether they actually knew if their physician had received payments. As well as very few people actually looked up the payments information about their doctors, so the utilization was pretty low, around something like 3% to 4%.
Then the third paper which came out in April, we looked at whether there was a change in trust among the people who responded to the survey. We didn't necessarily come in thinking this, but we found that it did decrease the trust that patients had in their own doctors.
Bear in mind, most of these people did not know whether their own doctor had received payments. But the disclosure itself of all these industry payments, we believe actually decreased the trust patients had in their own doctors, quite separate from whether their own doctors received payments or not.
A potential, industry-friendly, takeaway could be: The problem is transparency, not the payments. Basically, ignorance is bliss. Would you push back on that characterization?
KANTER: I'd be a little more subtle than that. The issue isn't transparency itself; the issue is the noisiness of the information that is being conveyed.
For sure, some physicians may be less trustworthy, and so people would be correct to update their information. But because the information they are receiving is at such a general level, so they don't know for their own particular physician which bin he or she falls in.
I would say physicians who aren't accepting payments are the most troublesome implication of this. Physicians who aren't receiving payments are painted with the same broad brush as those who are.
What we need is not just transparency, but more directed, more targeted, more informative transparency about payments to particular physicians.
What would your advice be for industry on engaging with physicians?
KANTER: This may seem like a sidebar, but when I was growing up, there was this hardware store. I can't remember what it was called, Big Joe's or something like that, that advertised honesty by saying 'If a competitor's selection or products were better, we would recommend you go to the competitor.'
I'm not saying Pfizer should become like Big Joe's, but I think industry leaders can gain both the public's trust and the physician's trust by being trustworthy and transparent in the information that they present to physicians when they engage the physicians.
Certainly acknowledging the weaknesses of the product, or build a better product and find the niche. Don't get your market share by gaming the system, misrepresenting your product or, god forbid, fraud. Get it by building a better product and doing what others don't do or can't do.
What do you make of GSK's decision last year to reverse its payment ban policy?
KANTER: It's certainly understandable as a strategic business decision. It may be hard to do it unilaterally, I think that's the inference we take from this.
This is a collective action problem — if policymakers, for example, think that this is a big enough issue that does require some broader regulation instead of voluntary action by individual firms. Because the individual firms won't have an individual incentive to do this if all the other firms are marketing in that way.
What's your prediction for the future — are these payments here to stay?
KANTER:I think certain kind of payments are likely to be around for a long time. Research payments, for example. Clinical trials are very expensive, and NIH doesn't have that amount of money unless it doubles or triples its budget. The soft money model of academic medical centers basically means that industry will have to fund these trials or a lot of research just won't get done.
We may see some shifts in certain kinds of payments, maybe related to food and drink and detailing, as doctors become more aware of the public backlash against this and voluntarily move away from accepting these payments. Also, physician practices and institutions may impose stricter rules on those kinds of interactions, so we may see a shifting away from that.
But it may be hard to predict. I'm drawing from two different sources of information to predict what's going to happen.
One is that Minnesota actually was the first state to enact the sunshine law at the state level. They disclosed their payments eons ago, like back in the '90s. What we saw was that over time there was a decline in industry payments.
Another is actually a completely different field, which is the disclosure of campaign contributions. That happened in the 1970s. The Federal Election Commission was created and all these donations were reported. What happened was we saw a lot of money that we perhaps never realized were going into campaigns, and it essentially normalized people's views of campaign contributions. People may get a little immune to it.
It's hard to know which way it's going to go at this point. I think the main message in relation to the study, in terms of transparency, we can't just take this 'let 1,000 flowers bloom' approach to disclosure.
Policymakers, researchers, firms are trying to figure out what might be the best way to keep legitimate industry-physician relationships while minimizing some of the things that might have more negative effects for patients and for physicians.